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December 2011 (Part 2)

By Jessica Kao, OREXer ’11-12

When I arrived in the morning at 7am, Dr. Harken and the residents weren’t there, and so there was no morning meeting. Although I wasn’t sure if there were still surgeries going on that day, I headed up to the fifth floor to check and saw on the board that there were still a couple surgeries, though there were much fewer cases than normal. The first surgery listed immediately caught my eye—I had always dreamed of watching a brain surgery, so I was very excited to see “Bicoronal Craniotomy with resection of brain mass” listed on the board.

I headed over to the OR, where the nurses were prepping all the instruments and tools. I was told that the surgery wouldn’t start until 8:30am, and was advised to make sure to eat breakfast and to put on one of the scrub jackets, since the surgery would likely last 12-13 hours. After the patient was brought in around 8:30am, the anesthesiologist, Physician Assistant named Larry, and nurses worked on intubating the patient. Because the patient had a smaller mouth and shorter neck, it took quite awhile for them to position her appropriately and to intubate her. After finishing the intubation, the anesthesiologist inserted the IV’s and then called for the attending, Dr. Moure, to come in for the surgery. The entire process of prepping the patient had taken awhile, so by the time the surgery officially began, it was already 10am. During that prep time, Larry was kind enough to answer many of my questions and to point out the MRI/CT scans of the brain tumor. The meningioma was a huge mass in the patient’s brain, which was why the surgery was going to take so many hours. The patient had been experiencing vision problems, and thus the purpose of resecting the mass was to prevent blindness. Larry also explained how anesthesiology had revolutionized the field of surgery by enabling surgeries to last more than the prior limit of 15 minutes, understandably due to the fact that patients could feel every bit of the surgery since they weren’t anesthetized. He stated that anesthesiologists are the “most important people in the hospital,” which I had never thought about before. Even considering the craniotomy that day, which would take 12-13 hours, that surgery wouldn’t even be fathomable without the anesthesiologist and his careful monitoring of the patient throughout the entire procedure.

After securing the patient’s head in place with clamps, Dr. Moure and Larry partially shaved the patient’s head, and one of the nurses scrubbed the shaved area in order to sterilize it. Two towels were draped around the designated area and stapled onto the skin. After the incision line was marked, a cover with a clear plastic area for the designated area on the head was draped over the patient. At this point, Dr. Moure was preparing to make the first incision when they realized that the Neptune suction device wasn’t working and that they would have to use the ventilator attached to the ceiling in the room. Dr. Moure was insistent on proceeding with the surgery only if the Neptune was functioning, since the suction from the ventilator wasn’t strong enough. They all scrambled to try to fix the Neptune, and Dr. Moure became more insistent that he didn’t want to proceed without strong enough suction. He wanted to cancel the procedure, but eventually began the surgery after Julie came in and firmly told him that the ventilator suction would be sufficient. The nurses later mentioned that the equipment dysfunctions that day—such as the malfunctioning suction device, a slightly faulty Raney clip applier, etc.—were because it was a complicated and demanding surgery that required many instruments.

After Dr. Moure made the incision along the marked line, Dr. Patel joined the surgery. They inserted Raney clips along both sides of the incision and pulled the scalp flap back to reveal the designated area (see image). They used an instrument to push away the dura, and then smeared bone wax (to control bleeding) on the skull. They then drilled holes and removed a rectangular sized piece of the skull, exposing the brain. They simultaneously used numerous surgical patties/strips to mitigate the bleeding. I learned from Jackson, one of the nurses, that the strips are specialized absorbent ones that are gentle enough to use in the brain. Since so many strips are utilized, it is imperative to keep count of how many are used, so that strips aren’t accidentally left in the incision—as a precaution, the strips are marked with X-ray detectable stripes. The surgeons then bent and placed metal rods to locate and designate the tumor, which was located in between the hemispheres. At this point, they were ready to proceed with getting rid of the brain mass, and Dr. Patel was kind enough to beckon me closer to show me all the different parts of the brain and surrounding areas that were now visible, including the eye sockets/balls, temporalis muscle, and left and right hemispheres of the brain. It was also breathtaking to see the exposed brain pulsating gently, as the surgeons prepared to start resecting the tumor mass.

Dr. Patel left for a meeting at that time, so the nurses assisted Dr. Moure in positioning the microscope equipment and his seat adjacent to the patient’s head, where he used the microscope to visualize the tumor. Primarily using Bovie bipolar forceps and the CUSA ultrasonic aspirator, Dr. Moure methodically got rid of the tumor bit by bit. It was amazing to watch him working via the video monitor and to see him eliminating the white tumor mass.

I left at 3:30pm since Dr. Moure was still working on resecting the tumor, and Larry said that the entire process would take awhile since the mass was quite large—the entire surgery was projected to last approximately until midnight or later. I am truly grateful for the opportunity to witness such a complex and awe-inspiring procedure, and I am very thankful for the helpful and encouraging staff who answered my questions, made sure that I was always comfortable throughout the many hours, and taught me so much about the procedure.